Healthcare Provider Details

I. General information

NPI: 1063454114
Provider Name (Legal Business Name): CARL STACEY BERG MASTER OF SCIENCE MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CARL JEFFREY BERG AU.D.

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 WILLIAMS HWY SUITE 105
GRANTS PASS OR
97527-5854
US

IV. Provider business mailing address

1867 WILLIAMS HWY SUITE 105
GRANTS PASS OR
97527-5854
US

V. Phone/Fax

Practice location:
  • Phone: 541-474-4694
  • Fax: 541-474-9590
Mailing address:
  • Phone: 541-474-4694
  • Fax: 541-474-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number20545
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier283606
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: